This application addresses broad challenge area (05) Comparative Effectiveness Research and specific challenge topic, 05-CA-104: Comparative Effectiveness Research on Cancer Treatment. Broad Objectives: The long-term objective of this work is to improve the quality of surgical care for breast cancer. One approach to improving the quality of care focuses on understanding and decreasing variations in practice across institutions. Specific Aims: This proposal seeks to investigate the degree of institutional variation in the surgical treatment of breast cancer in community hospitals. The majority of surgery for breast cancer is performed in community hospitals yet the majority of research is performed at academic medical centers. For that reason, a thorough understanding of practice patterns in community hospitals is crucial to improving the quality of care for breast cancer. In particular, this proposal investigates whether the supply of plastic surgeons and radiation oncologists at a given institution correlates with the type of surgery preferentially performed. This project has 3 specific aims: Aim 1. To determine the degree of institutional variation in the type of surgical procedure for early stage breast cancer in a cohort of U.S. community hospitals Aim 2. To evaluate the impact of institutional supply of sub-specialty care on the type of surgical procedure for early stage breast cancer Aim 3. To develop empirically evaluated, reusable, and freely available natural language processing software that can be used to access the ever increasing amount of electronic medical record data available Research Design and Methods: This project is a collaborative effort of government, non-profit and academic hospital information and research systems. Our cohort will include an estimated 4,500 breast cancer patients who underwent a definitive operation during 2007 or 2008 at one of 80 community hospital partners of IHM. Available data includes administrative and billing data, as well as free text reports from the electronic medical record. The first step is to design the software necessary to automatically and reliably extract data from the free text fields. This will provide accurate pathologic and other cancer-specific data required for this and any other analysis of cancer care in IHM hospitals. The second step is to use this data to compare the surgical treatment of breast cancer across institutions. Multivariable modeling will be used to investigate the relationship between institution and the type of surgery performed after controlling for patient and cancer-specific variables. In particular, the supply of plastic surgeons and radiation oncologists will be considered as possible explanations for institutional variations in the use of reconstruction and breast conserving surgery. Potential Impact: This study has the potential to have a major impact as follows: 1. Improve the quality of surgical care for breast cancer, affecting approximately 160,000 American women per year 2. Provide a new data source for comparative effectiveness and other health services research in a cohort of 80 community hospitals, representing an understudied sector of the U.S. healthcare system 3. Develop a modular approach to natural language processing software that can be re-used to access electronic medical record data and advance the field of comparative effectiveness and other health services research This proposal investigates institutional variation in the surgical treatment of breast cancer at community hospitals. In particular, we seek to determine whether the supply of plastic surgeons and radiation oncologists at a given institution correlates with the type of surgery preferentially performed. This project is a collaborative effort of government, non-profit and academic hospital information and research systems and will provide a new data source for comparative effectiveness and other health services research in community hospitals, an understudied sector of the U.S. healthcare system.